RN Utilization Review

• Where You’ll Work Founded in 1941, Dignity Health - Dominican Hospital is a 188-bed, acute care, nonprofit hospital located in Santa Cruz, California.
• Serving over 80,000 patients annually, the hospital offers a full complement of services including heart care, orthopedics, and a Family Birthing Center.
• Additionally, Dominican Hospital has been recognized as an LGBTQ+ Healthcare Equality High Performer by the Human Rights Campaign Foundation.
• It is a Joint Commission-certified Primary Stroke Center, and has been awarded the AMA/ASA’s Get the Guidelines - Stroke Gold Plus Quality Achievement, recognizing the hospital’s commitment to providing the best stroke care.
• One Community.
• One Mission.
• One California Job Summary and Responsibilities Responsible for the review of medical records for appropriate admission status and continued hospitalization.
• Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking.
• Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies.
• Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions.
• Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.
• Job

Requirements

Graduate of an accredited school of nursing upon hire Minimum two (2) years of acute hospital clinical experience Bachelor's Degree in Nursing (BSN) or related healthcare field. Masters degree in Case Management or Nursing field in lieu of 1 year experience. Licensure and Certifications: Registered Nurse: CA (RN:CA Preferred: years of nursing experience. Accredited Case Manager (ACM) Certified Case Manager (CCM)